This week on Safe As we covered three topics:
1) the effectiveness of leadership walks,
2) whether RCAs prevent incident reoccurrence,
3) The integration of systems approaches in construction investigations.
Ep 14:
Image 1 provides an extract from Foster et al.’s systemic review on leadership walkarounds (LWs) in healthcare.
From 12 studies they found several positive associations “of LWs with operational and perception of cultural outcomes”.
They argued that “Fundamentally, LWs show to help staff, nurses and physicians feel psychologically safer to report, discuss and learn from errors”.
Longer exposure to LWs combined with feedback mechanisms seemed to have greater positive effects.
Interestingly, some research (not all covered in this review) found worsening measures after LWs, like with trust or safety climate scores.
Ep 15:
Image 2 is an extract from Martin-Delgado et al’s systematic review of RCAs in healthcare.
They found while there could be definite improvements resulting from RCAs, “It is not clear if root cause analysis is effective in preventing the recurrence of adverse events”.
They further argued that while considerable benefits can result from RCAs to learn about the incident, “it does not seem to produce enough benefits to address and resolve the problem”.
They observe one key limitation: “RCAs are not usually accompanied by subsequent control of whether the devised improvement plan is carried out”.
Ep 16:
Image 3 captures the contributing factors in 100 construction investigations, mapped against Rasmussen’s risk management framework.
No surprises – but the majority of focus is placed at the proximal, local levels.
Image 4 shows the distribution of corrective action – with most focused on staff.
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Pod links:
Ep 14: https://spotifycreators-web.app.link/e/24hhWxcnrVb
Ep 15: https://spotifycreators-web.app.link/e/TxGE0wcnrVb
Ep 16: https://spotifycreators-web.app.link/e/kwdLovcnrVb
Image sources:
1. Foster, Meagan, and Lukasz Mazur. “Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review.” BMJ Open Quality 12.4 (2023): e002284.
2. Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis translates into improved patient safety: a systematic review. Medical Principles and Practice, 29(6), 524-531.
3 & 4. Woolley, M. J., Goode, N., Read, G. J., & Salmon, P. M. (2018). Moving beyond the organizational ceiling: Do construction accident investigations align with systems thinking?. Human Factors and Ergonomics in Manufacturing & Service Industries, 28(6), 297-308.
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